AFCA Upholds Insurer’s Decision in Breast Cancer Claim Case
AFCA Upholds Insurer’s Decision in Breast Cancer Claim Case
2
The information on this website is general in nature and does not take into account your objectives, financial situation, or needs. Consider seeking personal advice from a licensed adviser before acting on any information.
A recent ruling by the Australian Financial Complaints Authority (AFCA) has affected a woman’s critical illness claims, as her diagnosis came within mere days of her policy's eligibility period drawing to an end.
The woman was diagnosed with cancer in her right breast on October 5 of last year, followed by the discovery of cancer in her left breast eight days later. She filed claims under her critical illness policy that she had obtained on July 17.
However, TAL Life, her insurance provider, rejected the claims based on the policy's three-month qualifying period for cancer coverage.
In its ruling, AFCA noted that the policy had provisions to potentially waive the qualifying period if the policyholder could prove they were insured either under a previous TAL policy or by another insurer for the same events, right before their new coverage commenced.
The claimant contended that she had cancer coverage through an insurance policy provided by her husband's employer. She presented a letter from the employer affirming that she was covered under a "life, accident, critical illness, and medical insurance" scheme from August 2020 until June last year. Additionally, she showed documentation indicating her husband’s policy did include critical illness coverage for spouses, encompassing cancer.
While AFCA accepted the availability of this cancer coverage, it was not convinced that she held such coverage "immediately before the current policy began." It also noted she had failed to disclose her previous insurance when applying for the new policy with TAL Life.
"There is no information before me about the extent of the critical illness cover the complainant had, if any, through her husband's employer’s insurance arrangements," AFCA’s ombudsman stated.
"Furthermore, it appears that any cover she might have had ceased about a month before the new policy started. I am not convinced there was 'continuity of cover' as suggested by the complainant."
The ombudsman expressed AFCA’s sympathy towards the claimant, especially given that the diagnoses occurred "very close to the end of the qualifying period." Nonetheless, he emphasized that there was no valid reason for the qualifying period to be dismissed.
"The qualifying period is reasonably short and its existence is not unjust. These terms are part of all insurance policies and they draw necessary boundaries. The enforcement of these terms is not inherently unfair," the ombudsman elaborated.
For a more detailed account of the ruling, refer to the original report by AFCA.
QBE Australia Pacific has recently entered into a strategic partnership with Sure Insurance, aiming to bolster its broker-distributed householders cover. This collaboration signifies a concerted effort to provide more comprehensive and accessible home insurance solutions tailored to the diverse needs of Australian homeowners. - read more
Underwriting agency Blue Zebra has recently announced the establishment of new capacity arrangements for its home building and contents, landlord, and small to medium-sized enterprise (SME) package products. This strategic move is set to enhance the agency's ability to offer comprehensive and competitive insurance solutions tailored to the evolving needs of Australian homeowners and business operators. - read more
The Insurance Code Governance Committee has imposed a $30,000 penalty on AIG Australia for breaching its obligations related to claims handling. The insurer failed to inform customers about delays in processing their claims and neglected to advise them of their right to escalate complaints to the ombudsman. This regulatory action underscores the critical importance of transparency and communication in the insurance claims process. - read more
Australian homeowners are experiencing notable increases in home insurance premiums, a trend largely driven by the escalating frequency and severity of extreme weather events. Recent data indicates that average annual premiums for new home and contents policies have risen by 14%, equating to an additional $343 per year for policyholders. This surge is a direct response to the substantial claims resulting from natural disasters that have impacted various regions across the country. - read more
Reinsurance has emerged as a cornerstone of financial stability for Australian insurers, effectively shielding them from potential losses that could have reached up to $70 billion. In the past financial year, general insurers in Australia invested approximately AUD2.5 billion in reinsurance, a strategic move that has proven invaluable in mitigating the financial impact of increasingly frequent and severe natural disasters. - read more
Creating a monthly budget is essential for any business, but it holds particular importance for small trade businesses in Australia. Effective budgeting can help you manage cash flow, allocate resources efficiently, and ensure financial stability. - read more
Trades insurance is a specialised type of coverage designed to protect individuals and businesses in the trades industry. This category includes a wide range of professionals such as electricians, plumbers, builders, and other manual workers who face unique risks in their day-to-day operations. - read more
Budgeting is one of the most crucial aspects of running a small trade business. Without a proper budget, it's easy to lose track of your expenses and revenues, leaving you in a financial mess. This can be especially challenging for small trade businesses where margins are often tight, and a minor miscalculation can lead to significant issues down the line. - read more
Professional indemnity insurance (PI insurance) is a type of coverage designed to protect businesses and individuals who provide professional advice or services. It covers claims made against them for negligent acts, errors, or omissions in the performance of their professional duties. - read more
Trade insurance is an essential safeguard for subcontractors in Australia. It offers a safety net that protects against the uncertainties and inherent risks in the industry. Whether you're a plumber, electrician, or construction worker, having the right kind of insurance can mean the difference between financial stability and ruin. - read more
Knowledgebase
Umbrella Policy: An additional insurance policy that provides extra liability coverage beyond the limits of the insured's primary policies.
